Antibiotic Stewardship in Primary Care: Evidence from Pay-for-Performance in France

This paper investigates whether financial incentives for curbing antibiotic prescriptions are effective and how the design of incentives plays a role in influencing physician behavior. Using prescription-level data from French general practitioners over six years, I provide evidence of the incentives' effectiveness by exploiting variation in the set of diseases that the physicians treat as well as in the reward scheme. To understand how they respond, I propose a model that incorporates financial incentives into physician's decision-making and test the predictions of the model. The results highlight that the reduction in antibiotic prescriptions varies across different diseases, in line with the physicians' altruism and, hence, the patient's needs. Moreover, forward-looking physicians are influenced by the marginal cost of antibiotic prescriptions and the design of the incentives. While the program is effective, the magnitude is moderate, with a 2 percentage point drop in the antibiotic prescription rate. Comparing the effect to the cost of the program, conditioning the rewards on prescription rates rather than the improvement over time plays a role. As a result, while aggregate bonus payments per physician remain modest (on average 0.2% of physicians' annual income), the cost per avoided prescription is substantial (on average 56% of the fixed visit fee).